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S' _ SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SS Z _ SERVICE REQUEST Type of Business or Property CHECK if BILLING ADDRESS FACILITY ID # SERVICE REQUEST # PAYMENT RECEIVE'D MAY - 7 2C;3 SAN JOAQUIN COUNiv Ham'" UNMENTa,t ACCEPTED BY: zg2i HOME or MAILING ADDRESS oZc� 5-�a OWNER/ OPERATOR O Y\ 4 CHECK if BILLING ADDRESS FACILTY NAME CITY \ STATE ZIP Irk r��c S\2 R CA llevlys7 SERVICECODE: ,5'22- SIT'E]ADDRESS j+,�c�.,}75� Fee Amount:42-(D.01) tr�y�;v/tp,C:s !Z" Amount Paid NreD \ Payment Date 0((1PStreet Number Direction Street Name Invoice # ci Zip Code Received By: (YU HOME Or MAILING ADDRESS (If Different from Site Address) Street Number Street Name CITY STATE ZIP PHONE#1 EXT. APN # LAND USE APPLICATION # (2c -1 . oy?;� PHONE#2 EXr. BOS DISTRICT LOCATION, CODE CONTRACTOR/ SERVICE REQUESTOR REQUESTOR ktyg- CHECK if BILLING ADDRESS BUSINESS NAME PHONE# EXT' PAYMENT RECEIVE'D MAY - 7 2C;3 SAN JOAQUIN COUNiv Ham'" UNMENTa,t ACCEPTED BY: t7L[lJE[t2�4 HOME or MAILING ADDRESS EMPLOYEE#: Q?j� FAX# O Y\ 4 C a n e .. �c 0. 'already (WO 5 CITY \ STATE ZIP R\'�O BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or my business as identified on this form. I also certify that I have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, Standards, STATE and FEDERAL laws. APPLICANT'S SIGNATURE: Wil`—L DATE: PROPERTY/ BUSINESS OWNER 13 OPERATOR/ lkNAGER ❑ OTHER AUTHORIZED AGENT If APPLic.4NT is not the BILLING PARTY proof of authorization to sign is required Title AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information to the SAN JOAQU[N COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is nrovided to me or my representative. TYPE OF SERVICE REQUESTED: IeA�G f -E 4—=A C— E -t -t tl D EL 74 6—A -.J Cr --('E C&— COMMENTS: PAYMENT RECEIVE'D MAY - 7 2C;3 SAN JOAQUIN COUNiv Ham'" UNMENTa,t ACCEPTED BY: t7L[lJE[t2�4 EMPLOYEE#: Q?j� DATES l.71'U ASSIGNED TO: C a n e .. �c 0. 'already EMPLOYEE #: � � �`7 DATE: �5' �0 Date Service Completed (if completed): SERVICECODE: ,5'22- PIE:3&02- Fee Amount:42-(D.01) Amount Paid O Payment Date Payment Type / Invoice # Check # 3 U \ Received By: (YU EHD 48-02-025 SR FORM (Golden Rod) / REVISED 11/17/2003